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HomeMy WebLinkAbout15-253� � t o-am®� dlll��� CITY OF IOWA CITY 410 East Washington Street Iowa City, Iowa 52240-1826 (3 19) 356-5040 (319)356-5497 FAX IDENTIFICATION NO. (Office Use Only) APPLICATION FOR TAXICAB 1 MOTORIZED PEDICAB VEHICLE DRIVER (Police Department review must be made between 8 a.m. to 3 p.m., Monday - Friday) Failure to complete the "required" information will result in denial of the application First, Middle Last 1. Name(REQUIRED) z 2. Address (REQUIRED) i Y2 -Y 'D E, -M Ll e l - Ceteiq L V1 L LC((; 2 2- �P i 3. Contact Information (REQUIRED) Email: e3 a rob._ r n t t r?- h6 -Mm- Cel hone: 3 (/ 133 5! 7 (All written communication sent 4a. Chauffeur's License expiration date (REQUIRED) b. Taxicab Business Name (REQUIRED) _ Y L L G GU cA /3 , 5 Prior experience in transportation of passengers: �yFS .. 4 r ecq ✓S 6. Have you ever been arrested / charged with any misdemeanors and/or felonies in this State or elsewhere? 0 Type of offense What happened to the charge? (Circle one) Where Convicted Dismissed Deferred Suspended Plead Guilty 7. Have you been arrested/ charged with any traffic offenses in the last five years? Tyne of offense What happened to the charge? (Circle one) Where When Other D When Convicted Dismissed Deferred Suspended Plead Guilty Other 8. Has your driver's license or chauffeur's license been suspended or revoked In the last five years? O Type of offense Where When N c� 9. Have you ever applied to be an Iowa City taxi driver using a different name? If yes, please provide-fihe nami N u ~ .. Cr% r°"m DEPARTMENT OF CRIMINAL INVESTIGATION (DCI) REPORT AND STATEGERTIFIED DRIVING 'RECORD MUST ACCOMPANY THIS APPLICATION FOR POLICE CHIIEr,Rli TTI You must apply for an individual Department of Criminal Investigation Report (form available upon reques'o. (SECOND PAGE FOR REQUIRED SIGNATURE AND NOTARY) 02/2015 APPLICATION FOR TAXICAB VEHICLE DRIVER Page 2 er I hereby certify that I hav issued to me by the Iowa DepartmeofeXranspoo Transportation adlWt�Chauffeur's understand that bf I �Z y� issued on t, expiring falsely answer any questions in this application, that this app kation may be denied. I agree that in making this application, I consent to allow agents or employees of the City of Iowa City Iowa, in their discretion, to examine any and all records and documents relating to this application and I further agree that, if authorization to be a taxicab driver is granted, to comply at all times with all of the provisions of Itle 5,ahapter 2, of the City Code. (Needs to be signed in front of a Notary Public) Date 10A 6//5 Signature of Applicant STATE OF IOWA ) COUNTY OF JOHNSON ) on this day of Snhscribed and sworn to before me by R 11 �. t � I have reviewed this application, DCI report, and the State certified driving record of this applicant and have determined that there is no information which would indicate that the ace wouRi be detrimental to the safety, health or welfare of resi- dents of the City of Iowa City (Title 5, Chapter ^n A) v 7 Expiration !0/a/� -- Dat Signature of AFTER APPROVAL BY THE CITY CLERK OU ARE AUTHORIZED TO DRIVE A TAXICAB IN IOWA CITY FOR NO MORE THAN ONE YEAR FROM THE DATE LISTED ASignae!of City Clerk or designee W / ate �Tl Office Use Only a Ch y Approved application :—' DCI report _r. State certified driving record `• ` Website update v 0312015 Cie,k AXIDRIVBA GEAPPL92014amended DOC C4JiWVUA400T U` utqov SMARTER ! SIMPLER € :WWMEF DRIVES office of©river serves PO go,x T-204 I Des MJries_ PR `,030„-92G4 Pho,%,. 515-244-£}1241 605-532-i`521 jFaa 51`-2313-1837 Inquiry Date: Customer Name: Address: Certified Abstract of Driving Record 10/16/2015 DL/ID #: 527AG8848 (IA) CDL Permit Class: None 5836959 Adarob, Mukhtar Mohamed 1424 DENALI CT City/State: CORALVILLE, IA Class: 522411382 Mailing 1424 DENALI CT Address: 10/07/2014 Mailing CORALVILLE, IA City/State: 522411382 Date of 10/14/1969 Birth: Restriction Sex: M Class: D Audit #: 8509059 Issue Date: 10/07/2014 Expiration 10/14/2016 Date: Endorsements: 2 Restrictions: NONE Restriction None Supplement: IO History Information CLEAR DRIVING RECORD Name: Adarob, Mukhtar Mohamed DL/ID: 527AG8848 CDL Permit Issue Date: CDL Permit Expiration Date: CDL Permit Endorsements: CDL Permit Restrictions: ID Status: DL Status: CDL Status: CDL Permit Status: CDL Cert Status: CDL Med Status: None None None None None VAL None ELG None None Pursuant to Iowa Code §321.30, I, Kim Snook, Director of Office of Driver Services, Iowa Department of Transportation, do hereby certify that I am the custodian of the records held by the Office of Driver Services, that this is a true and accurate copy of an official record currently in the custody of said office, and that I have been authorized by the Director of the Iowa Department of Transportation to so certify. In witness whereof, I have caused my signature and the seal of the Department to be set upon this document, at Ankeny, Iowa this date: Name: Adarob, Mukhtar Mohamed DL/ID: 527AG8848 c� aiicif ,, c 10/16/2015w --a IO C, — :�; s C D. 0. t tl 7f •••••''g Office of Driver Services �.� —r” Iowa Department of Transportation _ .. c7 f�1 Name: Adarob, Mukhtar Mohamed DL/ID: 527AG8848 pet, 6. 2015 o,55AM Div Of Crlminal Invesaia I i 0 n N2 7&32 P. FrCM:01TV cr 'OWC Cny Clork OIII'& Sia 3o66d8� �o/OS/2u 15 123y J729'1 P.O U2/DDS To: STATE OF IOWA Criminal history Record Check Request Form, Iowa 0ivisiml of Crimbial fnvesEigation Support Upera(ions Burea1l, 1f1 Floor 215 E. 71" Street Des Moores, Iowa 50319 (315)725-6066 ._ . r __ rr_1._:_..III; ,.. ...... b,.,...,yA !`h..aL n,r DCI Account Number: 7m)' — F _ (ir applicable) — From: Litt/ of fovea Cid City Clerk's Office 410 E. Washington Streci 1, I1on e: 319-356-5041 Fast 319-356-5497 L t}81111LC1pp1 X�11 Wllll 0P P/lva �.aauuuo• awury La§t l�slne (Illandalory) .y.+���••-�e--_.-. First Nalne (mandatory) _ �xtddlE IYaeue (recommended) ICN T MaH�m�C Gender (mondatory) Social Security N tuber (recommended) Date of Dirth (manilaitory) b/ ail 9G 9 Male ©Female C24) r O Waiver rtTformafion: Without a signed witiver from the subject of the request, a Complete criminal history record may not be releasable, per Code of Iowst, Chapter 692.2= For com letc erlminal history record information, as allowed by lawy, Mways obtabl a waiver signature from the subject of the regaesl. Waiver Release: I herehygll'c perlbiSSion for the ahovecequcsi lu vQIIdYel an Iowa efillliOHl history rwm'd elleclh mth the Division of Cfiroinal I1Ive5lig21iml (DCI). Any criminal history data concerning mo Ilial is to imnined 11the DCl nlay h6 felemd'as allowed by lair. FiraiveeSigizarure:_ —�• -- Iowa Criminal History Record Check Results As of 10 -L-05 , a seatcb of the provided name and date of birth revealed i INo lata+a Criminal I-Iislory Record folrnd with DCI El Imma Criminal History Record attached, DCI g DCI iuitials� — DCI -77 (08/25/10) Rc ro�vcr Tim> Ort 1 901ra 19,17PM @n 9rf07 N (iQ use only)